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NEW YORK STATE

IGNITION INTERLOCK DEVICE PROGRAM - FINANCIAL DISCLOSURE REPORT

CONFIDENTIAL

FINANCIAL DISCLOSURE INSTRUCTIONS

IN ORDER TO BE PROCESSED AS AN APPLICATION FOR JUDICIAL CONSIDERATION OF FINANCIAL AFFORDABILITY, ALL

INFORMATION REQUESTED ON THIS REPORT MUST BE COMPLETELY, PROPERLY AND ACCURATELY PROVIDED. DATED

SIGNATURE OF THE DEFENDANT IS ALSO REQUIRED.

QUALIFYING INFORMATION SECTION *

DEFENDANT'S NAME LAST, FIRST, MI (MIDDLE INITIAL): ENTER DEFENDANT'S NAME.

ADDRESS: ENTER DEFENDANT'S MAILING ADDRESS

DEFENDANT'S LICENSE NUMBER: ENTER DEFENDANT'S DRIVER LICENSE NUMBER.

DATE OF BIRTH: ENTER DEFENDANT'S BIRTHDATE

LIVING ARRANGEMENTS AND LENGTH OF TIME IN CURRENT ARRANGEMENT: DESCRIBE THE DEFENDANT'S PRESENT LIVING

ARRANGEMENT AND THE LENGTH OF TIME IN THIS LIVING ARRANGEMENT (E.G. HOMELESS, MARRIED LIVING WITH SPOUSE

AND/OR CHILD(REN), SINGLE/DIVORCED/WIDOWED LIVING ALONE, SINGLE/DIVORCED/WIDOWED LIVING WITH CHILD(REN),

SINGLE/DIVORCED/WIDOWED LIVING WITH PARENTS WITH OR WITHOUT CHILD(REN), CO-HABITATING, LIVING WITH

RELATIVE(S) OTHER THAN SPOUSE OR PARENT).

LIST OTHER PEOPLE IN HOUSEHOLD: LIST ANY OTHER PEOPLE WHO LIVE IN THE SAME HOUSEHOLD WITH THE DEFENDANT,

INCLUDING SPOUSE AND ANY DEPENDENTS.

EMPLOYMENT STATUS: CHECK THE APPROPRIATE RESPONSE. IF EMPLOYED, PROVIDE ALL INFORMATION REQUESTED IN

THE "EMPLOYED" SECTION ONLY AND PROCEED TO THE "FINANCIAL REPORTING SECTION". DOCUMENTS THAT CAN BE USED

AS VERIFICATION OF EMPLOYMENT INCLUDE A RECENT PAY STUB OR A COMPANY OR EMPLOYER LETTER. IF UNEMPLOYED,

PROVIDE ALL INFORMATION REQUESTED IN THE "UNEMPLOYED" SECTION AND PROCEED TO THE "FINANCIAL REPORTING

SECTION". DOCUMENTS THAT CAN BE USED AS VERIFICATION OF UNEMPLOYMENT INCLUDE BENEFITS STATEMENT/CHECK

STUB FOR UNEMPLOYMENT BENEFITS, EMPLOYER LETTER, OR DISABILITY VERIFICATION.

FINANCIAL REPORTING SECTION **

DO NOT LEAVE ANY SPACES BLANK. PLACE A ZERO IN THE APPROPRIATE SPACE

IF THE DEFENDANT HAS NO SUCH INCOME OR EXPENSES.

A - MONTHLY INCOME FROM WAGES: ENTER TOTAL GROSS FOR ALL WAGES. THE FOLLOWING DOCUMENTS CAN BE USED AS

VERIFICATION: PAY CHECK STUB, W-2 FORM OR EMPLOYER STATEMENT.

B - MONTHLY INCOME FROM OTHER SOURCES: ENTER ALL INCOME RECEIVED FROM SOURCES OTHER THAN EMPLOYMENT.

("RENTAL INCOME" REFERS TO INCOME RECEIVED FROM RENTAL PROPERTY THAT IS OWNED BY THE DEFENDANT.) THE

FOLLOWING DOCUMENTS CAN BE USED AS VERIFICATION: PAYMENT STUB, MOST RECENT STATE OR FEDERAL TAX RETURN,

BANK STATEMENT, COURT RECORDS, LETTERS FROM THE BENEFIT OFFICE REGARDING MONTHLY BENEFIT AMOUNT, ETC.

C - MISCELLANEOUS INCOME DURING PAST 12 MONTHS: SPECIFY ALL OTHER INCOME, REGARDLESS OF SOURCE.

D - CURRENT BALANCES: SPECIFY ALL TYPES AND AMOUNTS.

E - PERSONAL PROPERTY: LIST THE MARKET VALUE OF ALL PERSONAL PROPERTY OWNED.

F - MONTHLY EXPENSES: ENTER ALL MONTHLY EXPENSES AS APPROPRIATE. THE FOLLOWING DOCUMENTS CAN BE USED AS

VERIFICATION: EXPENSE RECEIPTS, PAYMENT BOOK, MOST RECENT BILL.

SUBMIT 3 COPIES OF THIS COMPLETED REPORT TO THE SENTENCING COURT

DPCA-500IID-FDR Available at

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Form Dpca-500iid-Fdr - Ignition Interlock Device Program - Financial Disclosure Report